Tularemia -- New Jersey

On December 3, 1985, a 67-year-old woman died from tularemia in
a
New Jersey hospital. She had been admitted 7 days previously with
a
metabolic acidosis secondary to combined dehydration and sepsis.
On
admission, she had an "unhealing sore" on the first finger of her
right hand. Initial treatment included gentamicin and cefazolin,
as
well as insulin for uncontrolled, late-onset diabetes. After 3
days,
the treatment was changed to streptomycin. Despite these measures,
disseminated intravascular coagulation, respiratory failure, and
hypotension developed, and the woman died.

The case history showed that on November 9, 1985, an
18-year-old
neighbor had shot two rabbits behind his home in Gloucester County,
New Jersey. After eviscerating the animals, he gave them to the
patient and her 64-year-old husband, who skinned and froze the
rabbits. During the summer, the young man had noticed several dead
rabbits around his house and had attributed their deaths to
insecticide that had been sprayed on local fields. One of the two
rabbits he shot was noted to be losing its fur.

Two days after dressing out the rabbits, the young man became
ill
with an ulcerated hand lesion, axillary lymphadenopathy, and a
fever.
He was examined at the local hospital; no diagnosis was made, but
he
was treated with antipyretics. On November 23, his two
neighbors--the
recipients of the rabbits--were admitted to the local hospital.
They
both had sepsis and hand lesions. On November 26, following
instructions from the hospital, the young hunter was started on
streptomycin, and he recovered rapidly.

The woman's original titer for tularemia, drawn November 23,
was
less than 20. Her titer rose to 160 after 10 days. First samples
from both men were drawn late in the disease. The hunter's first
blood specimen was drawn on November 29, when his titer was 1,280.
It
was reported as 2,560 after 7 days. Blood specimens from the
husband
were drawn December 3, when his titer was 320, and the level rose
to
1,280 after 14 days.

The two rabbits were sent to CDC for analysis. Cultures from
the
bone marrow of both animals grew Francisella tularensis.
Reported by WE Parkin, DVM, State Epidemiologist, New Jersey State
Dept of Health; Div of Field Svcs, Epidemiology Program Office, Div
of
Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:Six cases of tularemia had been reported in New
Jersey
over the 5-year period prior to this outbreak. One case, in 1985,
was
also associated with rabbits. No tularemia deaths had been
reported
in the state in the previous 5 years.

The association between rabbits and human tularemia was first
documented in 1913 (1), and rabbit contact was implicated in 90% of
the more than 14,000 cases reported through 1944 (2). Although
bloodsucking anthropod vectors have accounted for an increasing
percentage of cases in more recent years, rabbits continue to be an
important source of infection (3).

In the United States, wild rabbits of the genus Sylvilagus
(cottontails, marsh rabbits, and swamp rabbits) present the
greatest
hazard (2). Jack rabbits and snowshoe hares are susceptible to
tularemia but have rarely been implicated as direct sources of
human
infection. The domestic rabbit (Oryctolagus cuniculus) has not
been
documented as a source of human tularemia (2).

Exposure of the skin or conjunctiva to blood and other
infectious
tissue while skinning and dressing rabbits account for most cases.
Ingestion of inadequately cooked meat has also been implicated. In
some instances pulmonary tularemia has resulted from breathing
aerosols generated while handling unopened rabbits or merely by
poking
at a dead rabbit with a stick (4,5). Indirect transmission from
rabbits to humans may result from bites by pet animals or deerflies
(6,7).

In 1939, the peak incidence year in the United States, 2,291
cases
(17.5/1,000,000 population) were reported (2). Only 291 cases
(1.2/1,000,000 population) were reported in 1984.

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